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Tuesday, December 29, 2015

Diffuse Esophageal Spasm and Nutcracker Esophagus

Diffuse Esophageal Spasm and Nutcracker Esophagus

A 34-year-old man complains of “crushing” chest discomfort for 1 hour. He has no significant medical history. The ECG is normal. He is given sublingual nitroglycerin in the emergency room that improves his chest pain almost  immediately.

Pathogenesis. Esophageal spastic disorders are idiopathic abnormalities of the neural processes of the esophagus. Fundamentally, diffuse esophageal spasm and nutcracker esophagus are the same disease. The only difference may be in the manometric pattern.
Clinical Presentation. These patients present with intermittent chest pain and dysphagia. The pain can simulate that of a myocardial infarction, but it bears no relationship with exertion. There is no relationship with eating, ruling out odynophagia. The pain can be precipitated by drinking cold liquids.
Diagnosis. Barium studies may show a “corkscrew”’ pattern at the time of the spasm. The most accurate test is manometric studies, which will show high-intensity, disorganized contractions. Because the contractions are disorganized, they do not lead to the forward flow of food and peristalsis.
Treatment is with calcium-channel blockers, such as nifedipine, and nitrates.

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